1. Identification and Diagnosis of the Acute Leukemias
Morphology - Romanowsky stain, special stains (Sudan black, MPO, esterases, PAS)
FAB A classification of leukemias based on morphology and predominant cell type.
Myeloid M1- M7 or Lymphoid L1-L3
Immunophenotyping By Flow Cytometry
Assign lineage Myeloid vs Lymphoid
Subclassify lymphoid (pre B, T cell etc)
Hybrid or mixed lineage

2. Identification and Diagnosis of the Leukemias
Genetics
Cytogenetics - Allows karyotyping of metaphase chromosomes
Rt-PCR - Allows detection and amplification of abnormal gene sequences

3. Acute Leukemias Epidemiology Uncommon Disease 1 - 3/100,000
Childhood 80% ALL v.s. 20% AML
Adult 20% ALL v.s. 80% AML
Difference likely reflects the susceptibility lymphoid/myeloid precursors to leukemogenic events at different ages

4. Signs & Symptoms Leukemic cells infiltrate ® Organomegaly Dysfunction
Lymph nodes ® Adenopathy
Liver/Spleen ® Hepatosplenomegaly
Skin/Gums
CNS ® Confusion/Decrease level of consciousness
Bone (rapid marrow expansion) ® PAIN

5. Signs & Symptoms
Marrow failure due to replacement of normal precursors by leukemic blasts
RBC ® Anemia ® Fatigue etc…..
WBC ® Infections (Leukemic WBCs not functional)
Platelets ® Hemorrhage
Hyperviscosity - seen in acute leukemias with extremely high WBC (>100)
Leukostasis - Confusion ® Coma
Respiratory Distress

6. Acute Lymphoblastic Leukemia
6 year old male
2 week history of bruising
fever of unexplained origin
CBC
LKC 32.3 x 10E9/L
HB 58 g/L
THR 20 x 10E9/L
95% blasts, 2% neutrophils, 3% lymphocytes

7. Acute Lymphoblastic Leukemia
Flow Cytometry shows presence of a large population of precursor B cells CD19+CD10+ colored red (Slide 1)
Absence of surface kappa or lambda light chains (Slide 2)
Negative for myeloperoxidase, population of cells positive for TdT (Slide 3)

8. Acute Lymphoblastic Leukemia
(Slide 1)
Acute Lymphoblastic Leukemia
CD45
CD4
CD8 SS
CD19+10+
CD19
CD2
CD10
CD20

9. Acute Lymphoblastic Leukemia (Slide 2)
CD 45 SS
CD19
CD19
KAPPA
LAMBDA

10. Acute Lymphoblastic Leukemia (Slide 3)
CD45 SS
CD45
CD45
MPO
TdT

11. DNA Analysis
By staining the nucleus of the cell with Propidium Iodide (PI) the DNA content relative to normal can be assessed.
Normal cells have a DNA index of 1.0
Abnormal cells (aneuploid) can have an increased (hyperdiploid) or decreased (hypodiploid) flow DNA index (D.I.)

12. Acute Lymphoblastic Leukemia
DNA Analysis
Patient +
Control
Patient
D.I. =1.0

13. Acute Lymphoblastic Leukemia
DIPLOID
ANEUPLOID
DNA INDEX 1.4